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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2020 0, - NOV 2 2 2019 * Please complete form and attach all necessary doe, nens by December 13iMilgki DEPT. Failure to do so will result in the return of youeupplicatron packet. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 154h. ESTABLISHMENT NAME: OLD lc.l NG 5 Co ef-EG TAX ID: LOCATION ADDRESS: I-11 0 u 4-Ca W arvv u tl1 mA 021013 TEL.#: `Z7E(• L(70.S d 8 MAILING ADDRESS: 4+-1 'Rni*L ,�8 W% ox vl-fn 1M h 62.6 E-MAIL ADDRESS: in-Po©ald Kin 3SGoc•Fe e. OWNER NAME: kite (nrliSS CORPORATION NAME IF APPLICABLE): Ok P-1 rts S Cv-flee L[--C MANAGER'S NAME: Kctie CorIr, s TEL.#: 5-08 3b 7 0 5—k MAILING ADDRESS: try grx.)fe at, GU. VA-re-Mali,M A 02107 3 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please lift the;lD Pool Operator(s) and attach a copy of the certificatiurrtotMs form. _ I 1. 2 .NO Z 2 2019 Pool operators must list a minimum of two employees currently certified in standard First Aid Anil ef14417tPT. Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past yearsrecords. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. yWa;>",_ C W r K 55 2. at k--4--FP-.e vo 6a_rnj PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. - I n 1. P.o r1I S S 2. a1 Ct,- w garnj ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 11141:e_ CUr VSS 2. 4-1ul'i1er Pep/ HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. ta'el i SS 2. ' 3. 020142-4-- 4. v ' Pelot RESTAURANT SEATING: TOTAL# L/ OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 MOTEL $110 _INN $55 CAMP $55 _SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PE # LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _L0-100 SEATS $125 s�( CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $200 / COMMON VIC. $60 WHOLESALE $80 RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 _VENDING-FOOD $25 <25,000 sq.ft. $150 —FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ /85.06 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED �d OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES J NO MOTELS AND OTHER LODGING ESTABLISHMENTS I'RANSTENTOCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy hh ll'be limitffto the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six (6) month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Department three(3)days prior to opening,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFÉS: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13, 2019. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY ' Vii,d IRE A SITE PLAN. / / DATE: /,/106) SIGNATURE: 0. A PRINT NAME&TITLE: 6L-It (JY/1 S T - Rev. 10/15/19 The Commonwealth of Massachusetts ►■ `i' f Department of Industrial Accidents fi E'=Y' Office of Investigations =lit= 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 41 rj Kin a o F�o� LLC a S Address: 17/1/ Roo/6 �J City/State/Zip: 1&Jes+ Ycu-yn ou-/-/i � rr2�1 Phone#: `j 7 y y7/3 s- b Are rou an employer? Check the appropriate box: Business Type(required): 1. I am a employer with q employees(full and/ 5. 0 Retail or part-time).* 6. Er Establishment 2.0 I am a sole proprietor or partnership and have no 7• 0 Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: 61\1 A Insurer's Address: POW\i h C . -In Strca nc� !-1C•P,Y1W City/State/Zip: - ,1,'G.r\i\tS 1 WV\ � b21D 01 Policy#or Self-ins.Lic.# c,(0(0 2 g 201 SZExpiration Date: (o I t l 20 2- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ' nder the pains and penalties of perjury that the information provided above is true and correct. Signature: 11/' � Date: JI% /( Phone#: .57)g ,&97 ODS` ' Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia Client#:766820 2OLDKI DATE(MMJDWYYYY) ACORD., CERTIFICATE OF LIABILITY INSURANCE 19 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CNAME:ACT Joanne Sullivan The Hilb Group of N.E.dba PHONE 508 775-1620 FAX 508 778-1218 (A/C,No,Ext): (A/C,No): Dowling&O'Neil Insurance Agy E-MAIL _ 1 suliivan@doins.com P.O. Box 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A;Continental Casualty Company 20443 INSURED INSURER B;CNA Insurance Companies 20478 Old Kings Coffee,LLC 540 Main Street,STE 18 INSURER c Hyannis,MA 02601 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. j RR TYPE OF INSURANCE IANSR WVD POLICY NUMBER SUBR POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY B6025207549 05/27/2019 05/27/2020 DISES(EAACCHp�OECTCpURRENCE $1,000,000 CLAIMS-MADE X OCCUR PREMEa axurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _$2,000,000 _ PRO- POLICY JECTX LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY (CEOMBINED SINGLE LIMIT accident) _$ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY (Per accident) _ B UMBRELLA UAB X OCCUR 6025229406 06/01/2019 06/01/2020 EACH OCCURRENCE $1,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ B WORKERS COMPENSATION WC625207552 06/01/2019 06/01/2020 X STA UTE EOTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) Operations performed by the named insured subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ' at ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S236110/M236107 JRS CNA 're'imiiitensation AndEmployers- tyr Insured Name Producer Information Old Kings Coffee LLC DOWLING & O'NEIL INSURANCEAGENCY 540 MAIN ST STE 18 973 IYANNOUGH RD HYANNIS, MA 02601 HYANNIS, MA 02601 Policy Number Producer Processing Code WC 6 25207552 120-045472 Policy Period CNA Branch 06/01/2019 to 06/01/2020 BOSTON 53 State Street Suite 510 New Business Boston, MA 02109 Thank you for choosing CNA! With your Workers Compensation And Employers Liability Insurance policy, you have insurance coverage tailored to meet the needs of your business. The international network of insurance professionals and the financial strength of CNA, rated "A" by A.M. Best, provide the resources to help you manage the daily risks of your organization so that you may focus on what's most important to you. Claim Services The Workers' Compensation Claim Kit will help you and your employees take full advantage of CNA's comprehensive services. We work with you, your employees and medical providers to promote workplace safety; control risks; facilitate early return to work when medically appropriate; prevent fraud; and assist you in recognizing your opportunities and responsibilities in managing Workers' Compensation costs. Go to www.cna.com/claim to obtain information on • How to report a loss • How to find a network provider • PPO panel request If you have questions or need additional information, you can call CNA customer Service at (877) 574-0540, or send an email to fsrmail@cnacentral.com, or contact your independent CNA Insurance Agent. State Required Posting Notices If you are not the person directly responsible for having these Posting Notices displayed, please direct these notices to the appropriate person within your organization. Posting Notices are required to be displayed in accordance with specific requirements as stated in the notices. The applicable notice(s) and the quantity included are based on the number of physical addresses in each covered state provided by your independent CNA Insurance Agent. Quality Assurance Questions pertaining to this transaction should be referred to CNA Customer Interaction Center at (877) 574-0540, Option 3. Please submit endorsements through www.cnacentral.com, send endorsement requests to ciet@cna.com or fax (877) 363-8669. ®Copyright CNA All Rights Reserved.